Patient-Centered Asthma Care Partnership

1. Patient-Centered Asthma Care Partnership By Evelin Viera, RN, CDE, TTS, AE-C Introduction and EMA. Introduction and EMA.

2. 1st GLFHC Site Before I begin talking about how we a the health center are MAKING STRIDES in bridging the gap between the patient and Provider. (PARTNERS) (GLFHC has evolved from humble beginnings above a funeral home (81 Bradford Street) with a staff of ten serving 3,000 patients in 1980, to a multi-site health organization with 500 employees now serving more than 43,000 patients)  Over 100 are Primary Care Providers Over 5000 patients are identified as having asthma w/in our EMR database (about 12%) Mission Statement: The mission of the Greater Lawrence Family Health Center is to improve and maintain the health of individuals and families in the Merrimack Valley by providing a network of high quality, comprehensive health care and services and by training health care professionals who can respond to the needs of a culturally diverse population. Health promotion Disease prevention Health maintenance Health restoration (“Increasing access to preventive health services is a goal of Healthy People 2010. This goal can best be achieved by delivering services where people live, work, play, or attend school, in their communities”) (Blais, Hayes, Kozier, Erb, 2006 p. 336) Before I begin talking about how we a the health center are MAKING STRIDES in bridging the gap between the patient and Provider. (PARTNERS) (GLFHC has evolved from humble beginnings above a funeral home (81 Bradford Street) with a staff of ten serving 3,000 patients in 1980, to a multi-site health organization with 500 employees now serving more than 43,000 patients)  Over 100 are Primary Care Providers Over 5000 patients are identified as having asthma w/in our EMR database (about 12%) Mission Statement: The mission of the Greater Lawrence Family Health Center is to improve and maintain the health of individuals and families in the Merrimack Valley by providing a network of high quality, comprehensive health care and services and by training health care professionals who can respond to the needs of a culturally diverse population. Health promotion Disease prevention Health maintenance Health restoration (“Increasing access to preventive health services is a goal of Healthy People 2010. This goal can best be achieved by delivering services where people live, work, play, or attend school, in their communities”) (Blais, Hayes, Kozier, Erb, 2006 p. 336)

3. Greater Lawrence Family Health Center Established in 1980 4 primary care neighborhood sites located throughout the city of Lawrence, MA 2 School Based Health Centers Serves over 43,000 patients (85% Latinos) 5200 or 12% have provider diagnosed asthma Leading primary health care provider in the Merrimack Valley area Lawrence is made of up 7 sq miles and has a total population of 72,492 (U.S. Census, 2003 estimate), of whom 43,277 or approximately 60% are Latino, primarily from the Dominican Republic and Puerto Rico.  Lawrence is the poorest city in Massachusetts (2000 U.S. Census), Lawrence is made of up 7 sq miles and has a total population of 72,492 (U.S. Census, 2003 estimate), of whom 43,277 or approximately 60% are Latino, primarily from the Dominican Republic and Puerto Rico. Lawrence is the poorest city in Massachusetts (2000 U.S. Census),

4. REACH 2010 LATINO HEALTH PROJECT 15 clinical outcomes were outlined A1c indicator <7% results: Diabetes Self Management Education (DSME) program was the main contributor to all the major health outcome indicator improvements Article Published: Online Journal of Health Disparities Research and Practice This was an 8 year CDC grant-funded project out the health center specifically aimed at preventing diabetes and improving the health outcomes of those with current diabetes. Over a span of 6 years, this project demonstrated significant improvements in diabetes related quality health indicators. DSME CONDUCTED BY BILINGUAL and OFTEN TIMES BICULTURAL RNs. All were vigorously trained in diabetes education through CEU’s (4 of the 7 were CDE prepared). More time spent with the patient*This was an 8 year CDC grant-funded project out the health center specifically aimed at preventing diabetes and improving the health outcomes of those with current diabetes. Over a span of 6 years, this project demonstrated significant improvements in diabetes related quality health indicators. DSME CONDUCTED BY BILINGUAL and OFTEN TIMES BICULTURAL RNs. All were vigorously trained in diabetes education through CEU’s (4 of the 7 were CDE prepared). More time spent with the patient*

5. Stats According to the MA Department of Public Health, Lawrence has an age-adjusted rate of hospital discharges for asthma that is 59% higher than the state average (187 discharges per 100,000 persons in Lawrence versus 128 statewide in 2002).

6. Quality Indicators Prevent asthma related deaths Improve overall Quality of Life Achieve optimal Asthma Control with least amount of medications necessary, while minimizing side effects Reach and maintain an Asthma Control Test (ACT) value as close to 20 as possible Decrease and/or avoid unnecessary ER/Urgent office visits from poor asthma control (minimize use of rescue medications) Prevent missed school and work from asthma morbidity Maintain normal or near normal pulmonary function Ensure that all patients are provided with an individualized self-management action plan (linguistically appropriate) (Results are still pending as we are still implementing the interventions and learning what work’s and what doesn’t with our system and specific population) ER REPORT shows downward trend, but statistically significant. (Results are still pending as we are still implementing the interventions and learning what work’s and what doesn’t with our system and specific population) ER REPORT shows downward trend, but statistically significant.

7. Goals An effectively informed patient who actively participates in treatment is more likely to undertake preventative measures, take medications properly, recognize signs of an attack, control an attack once it’s begun, and have a plan for emergencies as part of a successful asthma care partnership Describe the “asthma educator” and her role with patients. Describe the “asthma educator” and her role with patients.

8. Patient-Centered Comprehensive Asthma Care Asthma Educator/case manager serves as the link between all the members in the asthma care treatment team. Goal is to facilitate and move the patient through the change process in order to improve their health outcomes and Arm them with skills necessary to feel empowered to care for their own chronic disease. PCP (Dx, Tx, Evaluate, Monitor, some teaching) Asthma Ed (Ed, Assess, Teach Empowerment Skills, Facilitates connections between the patient and the provider at time, patient and the school nurse, the patient and pharmacist, the patient and specialist)….additionally, she connects the patient with CSW Case Manager for social issues i.e. Housing/Financial Help/Health Insurance/Transportation…. Connects them with nutrition services, as she may educated patients on the avoiding food allergies, and developing a meal plan to help lose weight.Asthma Educator/case manager serves as the link between all the members in the asthma care treatment team. Goal is to facilitate and move the patient through the change process in order to improve their health outcomes and Arm them with skills necessary to feel empowered to care for their own chronic disease. PCP (Dx, Tx, Evaluate, Monitor, some teaching) Asthma Ed (Ed, Assess, Teach Empowerment Skills, Facilitates connections between the patient and the provider at time, patient and the school nurse, the patient and pharmacist, the patient and specialist)….additionally, she connects the patient with CSW Case Manager for social issues i.e. Housing/Financial Help/Health Insurance/Transportation…. Connects them with nutrition services, as she may educated patients on the avoiding food allergies, and developing a meal plan to help lose weight.

9. Asthma Self-Management Education (ASME) Program Individualized Patient-Centered Asthma Education & Management (~4 office educational visits with educator) Educational plan includes basics of asthma, recognition of triggers, environmental control, symptoms and early warning signs, medication usage and side effects, use of spacer devices and peak flow meters if appropriate, and medical management of asthma exacerbations Based on the successes of the DSME program, and having been a Diabetes Educator of the program myself, when the opportunity to develop a similar comprehensive program for asthma I jumped at the opportunity to apply the same concept. Most of this intervention is delivered by both bilingual/bicultural educators. Currently, 5 part-time asthma educators covering all 5 sites. Culturally Competent Asthma Care Normative/Cultural Values Language Skills Folk illnesses Folk medicine/remedies (Broncholin/pneumoasma) Patient beliefs (cures) Training for staff (cultural/ linguistic/ professional development) CERTIFICATION PERCEPTION! Sustainibility= reimbursement received for nursing visit (education) under the medical director. (Feasible because we are a federally qualified CHC) (Anecdotal= CLOT, HBAI,…ER Report, and ACT on file)Based on the successes of the DSME program, and having been a Diabetes Educator of the program myself, when the opportunity to develop a similar comprehensive program for asthma I jumped at the opportunity to apply the same concept. Most of this intervention is delivered by both bilingual/bicultural educators. Currently, 5 part-time asthma educators covering all 5 sites. Culturally Competent Asthma Care Normative/Cultural Values Language Skills Folk illnesses Folk medicine/remedies (Broncholin/pneumoasma) Patient beliefs (cures) Training for staff (cultural/ linguistic/ professional development) CERTIFICATION PERCEPTION! Sustainibility= reimbursement received for nursing visit (education) under the medical director. (Feasible because we are a federally qualified CHC) (Anecdotal= CLOT, HBAI,…ER Report, and ACT on file)

10. Determining a Needs Assessment Establish rapport and build a relationship Tailored education and self-management plan Address the social determinants, language & cultural barriers, literacy level, and learning styles Facilitate empowerment (self-management) skills Raise expectations! Anecdotal success stories…Anecdotal success stories…

11. Community-Based Primary Asthma Care Gladys in the background and Dr. Glenn O’Grady. THANK YOU!!Gladys in the background and Dr. Glenn O’Grady. THANK YOU!!